Provider Demographics
NPI:1376884262
Name:PETERSEN, MARYANN MARIE (LMFT)
Entity Type:Individual
Prefix:MS
First Name:MARYANN
Middle Name:MARIE
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 N PRESCOTT ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-6820
Mailing Address - Country:US
Mailing Address - Phone:316-807-1037
Mailing Address - Fax:
Practice Address - Street 1:1223 N ROCK RD
Practice Address - Street 2:BLDG. G SUITE 100
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-1269
Practice Address - Country:US
Practice Address - Phone:316-636-2888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-03
Last Update Date:2013-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2454106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist